The limits of the universe inhabited by the physician-scientist are defined largely by time and money. In a Journal of Clinical Investigation editorial, Andrew Marks stated:8
“Historically, physician-scientists have had dual roles in caring for patients and in performing investigative research that could potentially lead to new diagnostics and therapeutics. Physician-scientists conducted teaching rounds in the hospital … and were often avidly pursued as the most important sources of new knowledge for trainees.
“… Now physician-scientists are rarely seen in the hospital; they are most often spotted at their desks tapping out yet another grant application. Most struggle to find the time to mentor students and clinical trainees, let alone to care for patients, even though these interactions are often the motivating forces for scientific creativity.”
These statements accompany a number of realities, as follows: Data collected by the American Medical Association from 1960 through 2005 show a major rise in the number of US physicians engaged in patient care while those involved in research and in teaching have been flat. Considering number of faculty in medical school departments and National Institutes of Health (NIH) grants funded over roughly the same period, PhDs are increasing in number, MDs are decreasing, and the number of MD-PhDs is flat. Of interest as well is that despite the efforts of NIH to fund young investigators, the trend over a 40-year period has been for the average age of research grant RO-1 recipients to increase, such that in 2005 approximately 35% of RO-1 principal investigators were over 50 years of age (as compared to about 22% 20 years earlier).
Barbara Weber has summarized the time and money issues confounding the physician-scientist as follows:9
“Three [critical] issues in academic medicine [are] having a serious negative effect on the pace and quality of academic … investigation. 1) The cost to creative time of ‘feeding the beast’ of the academic bureaucracy; 2) the innovation-squelching nature of the current peer review system; 3) the loss of physicians with a passion for clinical investigation as the leaders of academic medical centers.”
In this piece, she notes that a shift away from academic leaders being the leaders of academic medical centers has occurred because of the time drain of “feeding the beast” and that a premium is put on the financial bottom-line to the point that clinical investigation is no longer central to the mission statements of academic medical centers. She also notes that leadership is ever more in the hands of individuals who are not so much scientific leaders and role models as they are “businessmen”, who wind up being “adversaries to many faculty because of the business models under which they … operate”.9 this has been stated differently by Gary Koretzky: “It now seems that MD/MBAs may be more valued than MD/PhDs”.10
With regard to the judgment of research in an atmosphere in which funds are ever-more constrained, Weber offers advice that is sound, albeit rarely listened to these days.9 She states that reviewers should: “1) Focus on the big picture, and not … worry too much about details. 2) Ask, ‘Is this an important question, with plausible hypotheses?’ 3) Never say things like ‘overly ambitious’ or ‘it may not work’.” A neat coda is offered to this statement by Terry Strom who notes: “If we knew it would work it wouldn’t be research.”
With regard to the impact of NIH funding on the physician-scientist’s universe, it is not as if there isn’t a good deal of money in NIH. Rather, especially after the doubling of the NIH budget, the issue at present is in large part allocation of funds. A good illustration of how not to invest research funds – whether to physician-scientists or to scientists in general – is provided by the 2009 American Recovery and Reinvestment Act (ARRA). As part of an economic stimulus package this provided $10.4 billion to NIH. The Institute’s web site highlighted the ARRA funds as follows: “NIH’s two-year infusion of ARRA funds will empower the nation’s best scientists to discover new cures, advance technology, and solve some of our greatest health challenges.”11 The statement is an unfortunate, hard-sell advertisement of the potential benefits of the funding, rather than reflecting any sober assessment of what is really required to make scientific progress aimed at bettering health care. Consider that the review process for ARRA grants was tailored as little more than a questionnaire for reviewers to fill out and that at least one grant was funded in every US State plus Guam and US Virgin Islands. This was not the funding of science for the sake of supporting the best and the brightest: that likely could have been done better by simply giving the monies to NIH to support the best research being submitted and reviewed by traditional means. Indeed the only conclusion that one can reach re the ARRA grants process is that politics trumps science. This should not be taken to mean that some outstanding research was not funded by the ARRA process; it does mean that the entire process for evaluating research was side-tracked for political imagery and for short-term economic advantage.